HomeMy Public PortalAbout5062 SULTANA AVE_Mechanical__ DEC
WORKERS COMPENSATIONIhave cafe of cons APPLICATION FOR PERMIT
� I hereby affirm that I have a certificate of consent to self
insure or a certificate of Workers' Compensation Insurance, HEATING VENTILATING - AIR CONDITIONING
or a certified Sop thereof.Sec 3800, Lab C 76k-364C
07, 1 oc zt N� $?DDIe DPW 9'BB
Policy er ompurnciny ' d T COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy�is hereby furnished
Certified copy is filed with the-coun Inspec FOR APPLICANT TO FILL IN BUILDING
I d
part nt ADDRESS
r��J)� (PRINT OR TYPE ONLY) JC�L9 V L
Date Applicant ' LOCALITY
NO .TYPE OF APPLIANCE OR EQUIPMENT FEE r
+ CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
,II (This section naafi not be completed If the work Involved by - ABSORPTION UNIT Biu ' DISTRICT NO PROCESSED 9Y
the permit Is for one,hundred dollars ($100) or lass) AIR HANDLING UNIT CFM_-
I certify that in the performance of the work for which thisAIR
permit Is Issued, I shall not employ any person in any manner
sa as to become subject to the Workers'Compensation Lows BOILER BTU APPROVALS DATE NSqFMOR S SIGNATu
Date Applicant - COMPRESSOR BTU b O'O ROUGH
ii NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, .you should become subject to the Workers
^ Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER I VALIDA
with comp]y wnh such provisions or this permit shall be deem- -
i ed revoked FURNACE FAU_ VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU O JOG
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business WALL ,
and Professions Code,and my license Is In full force and effect Y
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License Number J 1 n SI' t is Class C- pop6
R -r�AC_ ee VS05F b
Contractor Dote ae
❑ 1 am exempt under Sec Plan check fee C
W
B 8P C for this reason IL
W
Date PERMIT ISSUING FEES p o
Signature t TOTAL FEE- So
OWNER-BUILDER DECLARATION - PLAN CHECK APPLICANT - — -
I hereby affirm that I am exempt from the Contractor s License - ►
Law for the following reason (Section 7031 5 Business and - NAME
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ACCTrO
the structure a not intended or offered for sole(Section CITY ,- _ TEL NO -
7044, Business and Professions Code) OWNER 3307 30.50
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec MAIL - 1 ITEMS
tion 704, Business and Professions Code) - ADDRESS r
TOTAL 30.SO
_ CONSTRUCTION LENDING AGENCY CITY TEL NO .s�E.Ir �^ ,
1 hereby offlrm that there Is a construction lending agency for, CHECK 30.50
the performance of the work for which this permit is issued CONTRACTOR y OQ'TT10& , x�l
(Sac 3097 Civ C ) _ C+sVeRS
ADDRESS Q �L'(� + _ ,
Lender's Name ' 'C1 - 6/26/89CITY ___ TEL tJ0 - - SSa� • '
Lender's Address
I certify that I have read this application and stole that the STATE �-p- UC Z 4175
above Information is correct I ogres to comply with all County LICENSE NO S ) p ClP'S5 1 AM 8C3]
ordinances and State jaws relating to budding construction - ' ' - -
and her asst rixe representatives of this County to enter
upon th a ve d property f r inspection purposes- - -- - - - -- -
�n SEE REVERSE FOR EXPLANATORY LANGUAGE r
SCF+ I -
Siq we of Applicant or Agent Dote -
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